Building the Universal Roadmap to Population Health Management Executive Webinar January 21, 2016 Karen Handmaker, MPP, PCMH CCE IBM Watson Health
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Flipping Healthcare : A Sign of the Times
Where is Your Organization On the Journey to Value? Max risk RISK TRANSFORMATION FULL CLINICAL RISK New risk contracts fail to return significant margins without clinical transformation OPTIMAL VALUE CREATION AND VALUE CAPTURE OPTIMAL CLINICAL DELIVERY Clinical transformation allows value creation to accrue predominantly to the payer CLINICAL TRANSFORMATION Max transformation 4
Where You Are in Your Transition to Value 32% 30% 25% 13% High readiness for risk, high clinical transformation High readiness for risk, low clinical transformation Low readiness for risk, high clinical transformation Low readiness for risk, low clinical transformation
PHM: Moving To A 24/7 Person-Centered Community Care Management Payer Patient Engagement Mobile Automated Outreach Patient Portals Patient Population of the Primary Care Office Clinical Analytics Clinical Decision Support Advanced Care Planning Claims and Cost Risk Stratification Primary Care Office Care of a patient Others who supply/require information and coordination Specialty CareHospitals Device Radiology, Lab, Rx Referral Tracking/HIEs Distance Monitoring Telehealth/Telemedicine Remote Patient Monitoring
It s Coming: Value-Based Payment Will Dominate Historical performance Goals 2015 2016 2017 2018 0% ~70% v ~20% 30% v 50% >80% 85% 90% Alternative payment models (Categories 3 4) FFS linked to quality (Categories 2 4) All Medicare FFS (Categories 1 4) http://www.hhs.gov/news/press/2015pres/01/20150126a.html 7
But, Preparing for Value is a Work In Progress PHM Strategy Confirmed Mixed Financial Incentives PHM Infrastructure Evolving Front Line Not Yet Top of License Buy/Affiliate to Complete Care Continuum FFS Dominant but Shifting Multiple Systems and Data Sources to Integrate Workflows Largely Manual and Vary Across Practices Secure ACO, CIN and Direct Employer Contracts FFS Contracts Include Quality Bonuses Analytics Initially Focused on Cost and Care Gaps Actionable Data Minimal Reduce Total Cost of Care Medicare and Commercial Shared Savings Interoperability Not There Yet Focused on Tip of the Iceberg Scale PCMH Funding for Care Teams Unstable Medical Neighborhood Loosely Coordinated Patient Engagement Episodic and Visit-Centered 8
Moving to Value Can be A Rollercoaster Ride FFS Peak Reduced ER Visits Reduce Re-admissions Reduce Admissions Reduced Specialty Visits Reduced Procedures/1000 Providers/Payors must embrace this transition. Reduced Revenue Revenue Control Loss Valley Population Management Peak Capitated Risk Gainshare Contracting Care Coordination/ Pt. Engagement PCMH/PCP Engagement EMR/Central Data Repository
Managing the Transition to Value is Key Increase Revenue FFS visits to close care gaps Medicare CCM fee PCMH and PHM incentives Medicare value payments to MDs Worksite clinics Decrease Costs Avoid admissions and readmissions Bundled payments Medicare Shared Savings Programs Manage self-insured risk Lean out waste 10
A New Model of Care Traditional View Patients Who Arrive New View Entire Patient Population Fee for Service Value Based Care
Value-Based Care Creates New Questions What is risk profile of my population? How do I compare to others on quality & costs? Who are my high-cost, high-risk patients? Which patients are likely to develop chronic conditions? How do I most effectively engage my population? How do I effectively manage them? How do I get paid for performance?
Bottom Up Model Drives Scale and Improvement QI Patient Engagement Enabled Care Teams Line of Sight Data Integrity 13
Requirements to Optimize PHM LEAN & Process Design Processes Efficient Ways of Working, Scale Automation Technology PHM and Engagement EMR Analytics Training People Knowledge, Skills, Teams, Leadership, Culture 14
HIT is Fundamental: Creating Smart Care Teams Current State Future State Care team Data & analytics Broad PCP-led team, with coordination across specialty and ancillary Integrated with hospital and specialty data using analytics based on clinical data and implied financial impact Patient-centered team fully integrated with specialty and ancillary that is multi-channel and 24/7 Integrated clinical, claims, financial, lifestyle, and biometric data providing real-time cognitive analytics Team activity Patient engagement pre/during/post visit using an approach based on patient segmentation Longitudinal engagement across care settings that is personalized and adaptive in real-time Workflow tools Clinical decision support tools within EMR and care management workflow solutions that leverage broad set of information Automated and actionable using full range of clinical, financial & lifestyle data, with a single integrated workflow across care team 15
Let s Harness The Exogenous Data to Drive Behavior Change Exogenous data (Behavioral, Socioeconomic Environmental) 1100 TB generated per lifetime 60% of determinants of health Genomics data 30% of determinants of health 6 TB generated per lifetime Clinical data 10% of determinants of health 0.4 TB generated per lifetime Source: The Relative Contribution of Multiple Determinants to Health Outcomes, Laura McGovern et al., Health Affairs, Health Policy Brief, 2014 16
Population Health: One Person at a Time Data and knowledge driven Every person has a plan Automation to manage a population down to the individual Team based 17
Roadmap Elements: Moving to Value Clinical, cost, & claims data integration Measure and track quality performance Historical and projected utilization Provider performance and variance Financial, future cost and risk management Predictive and cognitive analytics RISK MANAGEMENT Patient Experience Improved Quality CARE MANAGEMENT Decreased Cost Population profiling; risk stratification Identify and close care gaps Coordinate care and engage population continuously Transform care delivery model Advanced clinical decision support Lean out and scale care management 18
6 Pillars of PHM 1. Leadership and Culture and More Leadership. 2. Governance, Operational and Financial Model 3. Care Coordination Across the Continuum 4. Analytics and Performance Management 5. Evidence-Based Practices 6. Team-Based Care and Patient Engagement
A Tale of Two Organizations
1. Culture: Everything we do starts with you!
PHM Pillar 1: Culture Culture is critical but takes time to develop Identify & begin developing physician leaders early in the process While culture is developing, take the opportunity to layer in elements that support your PHM journey Get started, and keep the ball moving!
2. Governance, Operational & Financial Model
PHM Pillar 2: Governance, Operational and Financial Model Program Development Tier
3. Continuum of Care and Clinical Integration
PHM Pillar 3: Coordinating Care Across the Continuum Effective practice-based PHM is essential to successful Accountable Care
4. Actionable Data & Performance Scorecards
PHM Pillar 4: Data Analytics & Performance Measurement Stair-Step Approach: Move beyond data to INSIGHTS, DECISIONS and ACTION to realize value --------- Analytics Capabilities -------- Data Insights Data doesn t guarantee insights Data gathering & Analysis leads to the creation of improvement initiatives & program objectives Decisions Insights don t guarantee decisions --------------------- Analytics Value --------------------- Actions Decisions don t ensure actions. The last and often biggest step is the action of aligning data, process workflows, financial incentives, and strategy.
5. Evidence-Based Practices Team-based approach Standing orders/ Protocols/ Care Pathways
PHM Pillar 5: Evidence-Based Practices Clinical Guidelines NCQA Diabetes Recognition NCQA Heart Stroke Recognition Standing Orders Primary Care & Specialty Laboratory Disease Management Clinical Protocols & Pathways Process protocols Care Protocols
6. Team-Based Care and Consumer Engagement Patient-Family Advisory Councils Shared Medical Appointments Telehealth
PHM Pillar 6: Automation Drives High Performing Teams
Take Home Messages A universal roadmap to population health management is emerging Culture and leadership are absolutely critical and cannot be underestimated Technology is the big enabler for every PHM pillar (even Culture!)
Contact Karen Handmaker karen.handmaker@us.ibm.com What s Next? Care Team Transformation for Population Health Management Hosted by HIMSS Clinical & Business Community January 28 th from 1:00 2:00pm ET Register now for the event New Medicare Value-Based Physician Payment is Closer Than You May Think! Karen Handmaker and Dr. Laura Langmade, Clinical Informatics Analyst, IBM Watson Health February 11 th from 12:00 1:00pm CT Register now for the event